We are committed to providing you with the best possible dental care. Our fees reflect our
professional commitment to excellence. In order to achieve these goals, we need your assistance and
understanding of our payment policy. We offer the following methods of payment of fees:
- Payment in full is due at the time of service. We offer a 5% discount for accounts paid in
full at the time of service with cash or check. Insurance, credit, and debit card transactions are
ineligible for this discount.
- As a courtesy to our patients, we will file your insurance. It is the responsibility of the patient to
know the limits of your insurance. We cannot guarantee what your insurance will pay. We will
estimate as closely as possible what your out-of-pocket expenses will be. You will be
expected to make payment at the time of service for any deductibles or co-payments for
your treatment. If insurance claims take over 60 days to be paid by the insurance company,
we ask that the patient pay the balance in full and once the insurance pays the claim, we will
issue a refund if there is one coming to the patient.
- We also offer interest-free or extended payment plans through CareCredit dental financing
(O.A.C.). You may apply by going to www.carecredit.com If approved, print off approval with
your account number and bring to your appointment.
- In case of divorce or separation, the parent accompanying the child and authorizing
treatment will be the parent responsible for the charges on the day of service. If the
divorce decree requires the other parent to pay all or part of the treatment costs, it is the
authorizing parent’s responsibility to collect from the other parent.
We will gladly discuss your proposed dental treatment and answer any questions you might have as
to the involvement of your dental benefit program in receiving this care. We appreciate the opportunity
to serve you.
PAYMENT AGREEMENT:
I,authorize treatment for myself or minor, and agree to pay all fees and charges for such treatment. I understand that I am responsible for payment of any unpaid balance due from my insurance company, within 60 days of treatment. I understand that overdue accounts will be sent to a collections agency and I authorize release of protected information for collections purposes. I also agree to pay an interest penalty of 1.5% per month on any outstanding balance over 60 days. There will be a service charge on all returned checks. I acknowledge receipt of a copy of this agreement. All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
